LOAD Questionnaire

Thank you for agreeing to complete this questionnaire. Your assistance in this endeavor will enable us to gather valuable information about your pet and is a vital component in our ongoing quest to combat painful and debilitating diseases such as arthritis. It is important that all questions are answered to the best of your ability and if you have a question regarding the questionnaire, please contact us.

Thank you again for your help.


MM slash DD slash YYYY

Please choose which hospital you'd like to send it to:(Required)


Owner’s name:







Sex:


Background

1. How long has your pet been suffering with his/her mobility problem?(Required)





2. Has your dog been diagnosed as suffering from any other problems in addition to his/ her orthopedic disease?(Required)


Lifestyle

1. In the last week, on average, how far has your dog exercised each day?(Required)





2. In the last week, on average, how many walks has your dog had each day?(Required)






3. What type of exercise is this?(Required)





4. Are there particular days of the week upon which your dog has significantly more exercise?







(Check more than one box if necessary.)
5. On what sort of terrain does your dog most often exercise?(Required)




6. At exercise, how is your dog handled?(Required)



7. Who limits the extent to which your dog exercises?


Mobility

1. How is your dog’s mobility in general?(Required)





2. How disabled is your dog by his/her lameness?(Required)





3. How active is your dog?(Required)





4. What is the effect of cold, damp weather on your dog’s lameness?





5. To what degree does your dog show stiffness in the affected leg after a ‘lie down’?





6. At exercise, how active is your dog?(Required)





7. How interested is your dog in exercising?(Required)





8. How would you rate your dog’s ability to exercise?(Required)





9. What overall effect does exercise have on your dog’s lameness?(Required)





10. How often does your dog rest (stop/sit down) during exercise?(Required)





11. What is the effect of cold, damp weather on your pet’s ability to exercise?(Required)





12.To what degree does your dog show stiffness in the affected leg after a ‘lie down’ following exercise?(Required)





13. What is the effect of your dog’s lameness on his/her ability to exercise?(Required)











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480-210-5610

3109 E McKellips Rd,
Mesa, AZ 85213

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